Amputations through the midfoot

Lisfranc and Chopart amputations are frequendy

Chopart Level Amputation

Fig. 8.30 Transmetatarsal amputation, (a) Preoperative appearance of the right foot with a large necrotic wound at the site of a failed hallux amputation, (b) The plantar flap has been rotated medially to achieve closure of the surgical wound.

(c) Lateral radiograph reveals the level of amputation. Notice the angled cuts of the metatarsals. Stainless steel staples were used to close the wound, (d) Healed transmetatarsal amputation right foot.

Fig. 8.30 Transmetatarsal amputation, (a) Preoperative appearance of the right foot with a large necrotic wound at the site of a failed hallux amputation, (b) The plantar flap has been rotated medially to achieve closure of the surgical wound.

(c) Lateral radiograph reveals the level of amputation. Notice the angled cuts of the metatarsals. Stainless steel staples were used to close the wound, (d) Healed transmetatarsal amputation right foot.

complicated by the development of equinus deformity. Equinovarus deformity is associated with Lisfranc disarticulation. Amputation at the tarsometatarsal joints appears to be the most proximal level that allows for satisfactory function of the foot. For surgery to work at this level, care must be taken to preserve the base of the 5th metatarsal with its tendinous attachments, for eversion of the foot. The Achilles tendon should be lengthened, as necessary.

Chopart's mid-tarsal joint amputation has the advantage of producing less limb shortening than a Syme's procedure because the talus and calcaneus are retained.

However, complications are commonly reported with the Chopart amputation. Severe equinus deformity develops due to loss of the tibialis anterior, long extensor and peroneal tendons, with resultant failure to balance the force of the triceps surae. The resulting foot is short with a very small weightbearing surface, and is at increased risk of further breakdown. Some authors advise reattachment of the tibialis anterior to the talus to prevent equinus deformity of the hindfoot. However, long-term results demonstrate inevitable development of equinus deformity, even with tenotomy of the Achilles tendon.

Fig. 8.31 Technique for modified transmetatarsal amputation with excision of a plantar ulcer, (a) A triangular wedge is drawn on the skin, enclosing the plantar ulcer, (b) The forefoot has been amputated and the triangular wedge of skin has been excised, (c) Plantar flap prior to approximation of the two segments of skin, (d) Plantar flap has been repaired with simple interrupted sutures, (e) Completed repair with approximation of the dorsal and plantar skin flaps. From Sanders (1997) with permission from Elsevier Science.

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Fig. 8.32 Transmetatarsal amputation with excision of plantar ulcer, (a) Intraoperative view of the right foot, with the skin marked for excision of the plantar ulcer and creation of the plantar flap, (b) Completed transmetatarsal amputation with repair of the plantar flap. From Sanders (1997) with permission from Elsevier Science.

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